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HomeMy WebLinkAbout9.2 Motion to accept the proposal from Flock Group, Inc. to renew a two (2) year agreement for an amount not to exceed $137,000.00M+awn �'xytlts�=e Item Cover Page Subject Motion to accept the proposal from Flock Group, Inc. to renew a two (2) year agreement for an amount not to exceed $137,000.00 Meeting Fiscal Impact (Y/N) Dollar Amount Budget Source Category Type Information September 16, 2025 - REGULAR MEETING OF THE MOUNT PROSPECT VILLAGE BOARD 0 $137,000/ 2-year contract VILLAGE MANAGER'S REPORT Budget Item Maintaining public safety and the effective prevention and identification of crime is a top priority of the Mount Prospect Police Department. To assist in the deterrence of crime, gather evidence, identify offenders, locate missing persons and conduct investigations, the Village entered into an agreement in 2023 with Flock Group Inc. (Flock) for twenty-four license plate reader (LPR) cameras. Twenty-three of those LPR cameras were pole mounted (permanent) and one LPR camera was portable. Flock LPR cameras take a photograph of the rear side of a vehicle as it passes by a Flock LPR camera. The camera's software then compares the license plate number to a known list of wanted vehicles and alerts the department, in real time, to stolen vehicles, missing persons, or vehicles wanted in connection with other crimes. Since implementation of Flock LPR cameras, numerous investigative leads have been established, criminals identified, and missing people located. Discussion In 2023, with the Village Board's approval, the Village entered into a two-year agreement with Flock to provide the Village with these LPR's. The two-year agreement was set to expire on July 20, 2025. Due to ongoing negotiations with Flock continuing past the July 20th expiration date, Flock extended the Village's service until staff could bring the finalized agreements for a renewal to the Village Board. Staff would like to continue this partnership, allowing officers and detectives to keep using this resource. The current agreement called for 24 LPR cameras (23 permanent mounted and 1 portable). Due to permitting issues which were beyond the control of Flock or the Village, only ten permanently mounted LPR cameras have been installed to date. The Village also has one portable LPR, leaving with thirteen permanently mounted LPR's that still need to be installed by Flock, once IDOT or Cook County approve the respective permits. The Village has not incurred any fees or costs for these uninstalled LPR'S. Given the experienced delays in the permitting approval process, staff worked with Flock to modify the current agreement. The Department is looking to make amendments to the original agreement (Attachment A) and enter into the following two product / service agreements with Flock. Agreement 1 (Attachment B):Upon the effective date of the 24-month order, the Department would be billed for the ten mounted and operational LPR cameras, the one portable and operational LPR camera, and provide personnel with access to Flock's software, known as Flock Safety Advance Search, at a cost of $36,000.00 per year. Year 1 upon executed agreement $36,000.00 Year 2 $36,000.00 Total Contract Cost For This Agreement $72,000.00 Agreement 2 (Attachment Q: This agreement references the thirteen (13) uninstalled LPR cameras that have been delayed via the permitting process. The Village would be invoiced upon the last camera installation. The annual cost is $32,500.00, amounting to a total cost of $65,000.00. Year 1 invoiced at final installation $32,500.00 Year 2 $32,500.00 Total Contract Cost For This Agreement $65,000.00 By entering into these two agreements, the Village would only be required to pay for the cameras that are installed and operational. The funds for Flock have been budgeted for in the 2026 budget. Cost For Agreement 1 and Agreement 2 Combined: Agreement for 10 installed cameras (year 1) 36,000.00 Agreement for 10 installed cameras (year 2) 36,000.00 72,000.00 Agreement for 13 uninstalled cameras (year 1) 32,500.00 Agreement for 13 uninstalled cameras (year 2) 32,500.00 65,000.00 TOTAL COST FOR FLOCK CAMERAS OVER 2 YRS 137,000.00 It was discovered Flock's software had allowed some law enforcement agencies from around the country to conduct license plate searches and access data collected by Illinois law enforcement LPR cameras in conflict with and violating Illinois Law. Upon being notified, Flock immediately implemented additional safety measures to prevent the illegal access of LPR camera data for its Illinois law enforcement customers. Based on this experience and with the help of the Village's Corporate Counsel, staff negotiated with Flock to amend the agreement. Staff were seeking protection for the Village and its team members, should camera data be accessed, without staff's knowledge, in violation of Illinois law, as a result of Flock's software. The modifications were accepted by Flock and are included in all three documents (Attachment A - Amendment, Attachment B - Order Form, and Attachment C - Exhibit A Order Form). Alternatives 1. Accept the proposal from Flock to split our current contract into 2 separate agreements (1 for our installed cameras and 1 for our uninstalled cameras) and accept the proposal from Flock to renew our service for a 2-year period, with a total cost not to exceed $137,000. 2. Action at the discretion of the Village Board Staff Recommendation Staff recommends the approval of Flock's proposal to split our contract into 2 separate agreements (1 agreement for our installed cameras and 1 agreement for our uninstalled cameras) and approve Flock's 2-year renewal for services with the Village, with a total cost not to exceed $137,000. Attachments 1. IL - Mount Prospect PD - Amendment Order Form - (HP 8.19.25) 2. IL - Mount Prospect PD - Law Enforcement Agreement (Renewal) (1) 3. IL - Mount Prospect PD - Law Enforcement Agreement (13 Falcons) f i"ock safety AMENDMENT This amendment ("Amendment") supersedes and amends the previously executed agreement between the Parties, dated 7/20/2023, relating to the provision of services by Flock Group Inc. ("Flock") to IL - Mount Prospect PD ("Customer") and any schedules or exhibits attached thereto or incorporated therein by reference (the "Agreement"). The remainder of the Agreement shall remain in full force and effect. In the event of a conflict between this Amendment and the Agreement the terms of this Amendment will prevail. Any capitalized terms used in this Amendment will have the same meaning as in the Agreement, unless expressly defined otherwise. This Amendment is effective upon execution by both Parties (the "Effective Date"). The Parties agree as follows: 1. Section 3.2 of the Agreement is amended to read as follows: 3.2 Customer Representations and Warranties. Customer represents, covenants, and warrants that Customer shall use Flock Services only in compliance with this Agreement and all applicable federal, state and local laws and regulations, including but not limited to 625 ILCS 5/2-130(b)(1) and/or (b)(2), and any laws relating to the recording or sharing of data, video, photo, or audio content. 2. Section 4.2 of the Agreement is amended to read as follows: 4.2 Customer Generated Data. Flock may provide Customer with the opportunity to post, upload, display, publish, distribute, transmit, broadcast, or otherwise make available, messages, text, illustrations, files, images, graphics, photos, comments, sounds, music, videos, information, content, ratings, reviews, data, questions, suggestions, or other information or materials produced by Customer ("Customer Generated Data"). Customer shall retain whatever legally cognizable right, title, and interest in Customer Generated Data. Customer understands and acknowledges that Flock has no obligation to monitor or enforce Customer's intellectual property rights of Customer Generated Data. Customer grants Flock a non- exclusive, irrevocable, worldwide, royalty -free, license to use the Customer Generated Data for the purpose ofproviding Flock Services, unless Flock's use of the Customer Generated Data, violates laws concerning Customer's use and distribution of its LPR data, including 625 ILCS 5/2- 130. Flock does not own and shall not sell Customer Generated Data. 3. Section 4.4 of the Agreement is amended to read as follows: 4.4 Data Distribution. Customer may, upon request, choose to integrate Flock Services with a third party to either distribute Integration Data or Customer Data (such third party, "Recipient"). Upon such request, Customer hereby grants to Flock a non-exclusive, non -transferable, royalty -free, perpetual license to access, share, view, record, duplicate, store, save, reproduce, modify, display, and distribute Customer Data and/or Integration Data, as required by the requested distribution, unless such accessing, sharing, viewing, recording, duplicating, storing, saving, reproducing, modifying, displaying, and distributing Customer Data and/or Integrated Data, including Customer's LPR data, as required by the requested distribution violates federal, state, and/or local laws applicable to Customer, including 625 ILCS 5/2-130. Customer acknowledges that such data may be viewed, recorded, duplicated, stored, saved, reproduced, modified, displayed, distributed, and retained by Recipient for a period longer than Flock's standard retention period and hereby provides consent to such retention period. Unless expressly listed in the Order Form, the provision, access, or use of any Application Programming Interfaces ("APIs") is not included under this Agreement. Any rights, licenses, or obligations related to APis shall be governed solely by the terms set forth in the Order Form or a separate agreement between the parties. 4. Section 9.3 of the Agreement is amended to read as follows: 9.3 Flock Indemnity. Flock shall indemnify and hold harmless Customer, its agents and employees, from liability of any kind, including claims, costs (including defense) and expenses, on account of (i) any copyrighted material, patented or unpatented invention, articles, device or appliance manufactured or used in the performance of this Agreement; (ii) any damage or injury to property or person directly caused by Flock's installation of Flock Hardware, except for where such damage or injury was caused solely by the negligence of the Customer or its agents, officers or employees; or (iii) the dissemination or distribution by Flock of Customer Data, including Customer's LPR data, that results in a violation of Illinois law, including but not limited to, 625 ILCS 5/2-130(b)(1) and/or (b)(2). Flock's performance of this indemnity obligation shall not exceed the fees paid and/or payable for the services rendered under this Agreement in the preceding twelve (12) months. 5. Section 11.1 of the Agreement is amended to read as follows: 11.1 Compliance with Laws. Parties shalt comply with all applicable local, state and federal taws, regulations, policies and ordinances and their associated record retention schedules, including responding to any subpoena request(s) or laws governing the disclosure and dissemination of Customer Data, including 625 ILCS 5/2-130(b)(1) and (b)(2). 6. Any applicable Flock Hardware/Software, Professional Services and/or One Time Purchases listed on the table(s) below are removed from the Agreement in its entirety. Hardware and Software Products Annual recurring amounts over subscription term Flock Safety LPR Products Flock Safety LPR flea Falcon Included -13 Included Professional Services and One Time Purchases Annual Recurring Reduction:-$32,500.00 By executing this Amendment, Customer represents and warrants that it has read and agrees to all of the terms and conditions contained in the previously executed Agreement. FLOCK GROUP, INC. Customer: IL - Mount Prospect PD By: By: Name: Name: Title: Title: Date: Date: PO Number: f i"ock safety Wtj11W:a0[1].7UI This order form ("Order Form") hereby incorporates and includes the terms of the previously executed agreement (the "Terms") which describe and set forth the general legal terms governing the relationship (collectively, the "Agreement" ). The Terms contain, among other things, warranty disclaimers, liability limitations and use limitations. This additional services Agreement will be effective when this Order Form is executed by both Parties (the "Effective Date") Customer: Legal Entity Name: Accounts Payable Email: Address: IL - Mount Prospect PD IL - Mount Prospect PD metemo@mountprospect.org 911 East Kensington Road Mount Prospect, Illinois 60056 Hardware and Software Products Annual recurrine amounts over subscrintior Initial Term: 24 Months Renewal Term: 24 Months Payment Terms: Net 30 Billing Frequency: Annual Retention Period: 30 Days Flock Safety Platform Flock Safety Platform - Essentials Included 1 included Flock Safety LPR Products Flock Safety LPR, tka Falcon Included 10 Included Flock Safety LPR Flex, &a Falcon Flex Included 1 Included Flock Safety F1ockOS Add Ons Flock Safety Advanced Search Professional Services and One Time Purchases Included 1 Included Subtotal Year 1: $36,000.00 Annual Recurring Subtotal: $36,000.00 Estimated Tax: $0.00 Contract Total: $72,000.00 Taxes shown above are provided as an estimate. Actual taxes are the responsibility of the Customer. This Agreement will automatically renew for successive renewal terms of the greater of one year or the length setforth on the Order Form (each, a "Renewal Term') unless either Party gives the other Party notice of'non-renewal at least thirty (30) days prior to the end of the then -current term. The Term for Flock Hardware shall commence upon first installation and validation, except that the Term for an v Flock Hardware that requires self - installation shall continence upon execution of the Agreement. In the event a Customer purchases more than¢ one type of Flock Hardware, the earliest Term start date shall control. In the event a Customer purchases software onlv, the Termn shall commence upon execution of the Agreement. Special Terms: • This term shall be effective 7/20/2025 - 7/19/2027 • Section 3.2. Customer Representations and Warranties. Customer represents, covenants, and warrants that Customer shall use Flock Services only in compliance with this Agreement and all applicable federal, state, and local laws and regulations including but not limited to 625 ILCS 5/2-130(b)(1) and/ot (b)(2), and any laws relating to the recording or sharing of data, video, photo, or audio content. • Section 4.2. Customer Generated Data. Revise the next to last sentence in section 4.2 to read as follows: Customer grants Flock a non-exclusive, irrevocable, royalty -free, license to use the Customer Generated Data for the purpose of providing Flock Services, unless Flock's use of the Customer Generated Data, violates laws concerning Customer's use and distribution of its LPR data, including 625 ILCS 5/2-130. • Section 4.4. Data Distribution. Revise the second sentence in section 4.4 to read as follows: Upon such request, Customer hereby grants to Flock a non- exclusive, non -transferable, royalty -free, perpetual license to access, share, view, record, duplicate, store, save, reproduce, modify, display, and distribute Customer Data, as required by the requested distribution, unless such accessing, sharing, viewing, recording, duplicating, storing, saving, reproducing, modifying, displaying, and distributing Customer Data and/or Integrated Data, including Customer's LPR data, as required by the requested distribution violates federal, state, and/or local laws applicable to Customer, including 625 ILCS 5/2-130. • Section 9.3. Flock Indemnity. Add at the end of the first sentence of section 9.3 the following: ; or (iii) the dissemination or distribution by Flock of Customer Data, including Customer's LPR data, that results in aviolation oflllinois law, including but not limited to, 625 ILCS 5/2-130(b)(1) and/or (b)(2) • Section 11.1. Compliance with Laws. Add to the end of section 11.1 the following: Parties shall comply with all applicable federal, state, and/or local laws governing the disclosure and dissemination of Customer Data, including 625 ILCS 5/2-130(b)(1) and (b)(2). Billing Schedule Year 1 At Contract Signing $36,000.00 Annual Recurring after Year 1 $36,000.00 Contract Total $72,000.00 *Tax not included Product and Services Description Law enforcement grade infrastructure -free (solar power + LTE) license plate recognition camera with Vehicle Fingerprint Tm technology (proprietary Flock Safety LPR, fka Falcon machine learning software) and real-time alerts for unlimited users. Advanced Search is an optional upgrade for Law Enforcement Grade Falcon cameras. Advanced Search includes Convoy Analysis, Multi Geo Flock Safety Advanced Search Search, and Visual Search. Flock Safety LPR Flex, fka Falcon Law enforcement grade tactical deployment (portable + LTE) license plate recognition camera with Vehicle Fingerprint TM technology (proprietary, Flex machine learning software) and real-time alerts for unlimited users. An integrated public safety platform that detects, centralizes and decodes actionable evidence to increase safety, improve efficiency, and connect the Flock Safety Platform - Essentials community. FlockOS Features & Description The ability to request direct access to feeds from privately owned Flock Safety LPR cameras located in Community Network Access neighborhoods, schools, and businesses in your community, significantly increasing actionable evidence that clears cases. Unlimited Users Unlimited users for FlockOS State Network (License Plate Lookup Only) Allows agencies to look up license plates on all cameras opted into the Flock Safety network within your state. With the vast Flock Safety sharing network, law enforcement agencies no longer have to rely on just their Nationwide Network (License Plate Lookup Only) devices alone. Agencies can leverage a nationwide system boasting 10 billion additional plate reads per month to amplify the potential to collect vital evidence in otherwise dead-end investigations. Law Enforcement Network Access The ability to request direct access to evidence detection devices from Law Enforcement agencies outside of your jurisdiction. Time & Location Based Search Search full, partial, and temporary plates by time at particular device locations License Plate Lookup Look up specific license plate location history captured on Flock devices Vehicle Fingerprint Search Search footage using Vehicle FingerprintTM technology. Access vehicle type, make, color, license plate state, missing / covered plates, and other unique features like bumper stickers, decals, and roof racks. insights & Analytics Reporting tool to help administrators manage their LPR program with device performance data, user and network audits, plate read reports, hot list alert reports, event logs, and outcome reports. Receive automated alerts when vehicles entered into established databases for missing and wanted persons Real -Time NCIC Alerts on Flock ALPR Cameras are detected, including the FBI's National Crime Information Center (NCIC) and National Center for Missing & Exploited Children (NCMEC) databases. Unlimited Custom Hot Lists Ability to add a suspcct's license plate to a custom list and get alerted when it passes by a Flock camera By executing this Order Form, Customer represents and warrants that it has read and agrees to all of the terms and conditions contained in the previously executed agreement. The Parties have executed this Agreement as of the dates set forth below. FLOCK GROUP, INC. Customer: IL - Mount Prospect PD By: By: Name: Name: Title: Title: Date: Date: PO Number: f i"ock safety Customer: IL - Mount Prospect PD Legal Entity Name: IL - Mount Prospect PD Accounts Payable Email: metemo@mountprospect.org Address: 911 East Kensington Road Mount Prospect, Illinois 60056 Hardware and Software Products Flock Safety LPR Products Flock Safety LPR, fka Falcon Professional Services and One Time Purchases Flock Safety Professional Services EXHIBIT A ORDER FORM Initial Term: 24 Months Renewal Term: 24 Months Payment Terms: Net 30 Billing Frequency: Annual Plan - Invoiced at Last Camera Validation. Retention Period: 30 Days Included 13 Tncludcd $32,500.00 Subtotal Year 1: Annual Recurring Subtotal: $32,500.00 Estimated Tax: $0.00 Contract Total: $65,000.00 Taxes shown above are provided as an estimate. Actual taxes are the responsibility of the Customer. This Agreement will automatically renew for successive renewal terms of the greater of one year or the length set forth on the Order Form (each, a "Renewal Term') unless either Party gives the other Party notice of non -renewal at least thirty (30) days prior to the end of the then -current term. The Term for Flock Hardware shall commence upon first installation and validation, except that the Term for at v F(ockHardware that requires sell-' installation shall commence upon execution of the Agreement. In the event a Customer purchases more than one type of Flock Hardware, the earliest Term start date shall control. In the event a Customer purchases software only, the Term shall commence upon execution of the Agreement. Special Terms: Section 3.2 of the Agreement is amended to read as follows: 3.2 Customer Representations and Warranties. Customer represents, covenants, and warrants that Customer shall use Flock Services only in compliance with this Agreement and all applicable federal, state and local laws and regulations, including but not limited to 625 ILCS 5/2-130(b)(1) and/or (b)(2), and any laws relating to the recording or sharing of data, video, photo, or audio content. Section 4.2 of the Agreement is amended to read as follows: 4.2 Customer Generated Data. Flock may provide Customer with the opportunity to post, upload, display, publish, distribute, transmit, broadcast, or otherwise make available, messages, text, illustrations, files, images, graphics, photos, comments, sounds, music, videos, information, content, ratings, reviews, data, questions, suggestions, or other information or materials produced by Customer ("Customer Generated Data"). Customer shall retain whatever legally cognizable right, title, and interest in Customer Generated Data. Customer understands and acknowledges that Flock has no obligation to monitor or enforce Customer's intellectual property rights of Customer Generated Data. Customer grants Flock a non- exclusive, irrevocable, worldwide, royalty -free, license to use the Customer Generated Data for the purpose ofproviding Flock Services, unless Flock's use ofthe Customer Generated Data, violates laws concerning Customer's use and distribution ofits LPR data, including 625 ILCS 5/2- 130. Flock does not own and shall not sell Customer Generated Data. Section 4.4 of the Agreement is amended to read as follows: 4.4 Data Distribution. Customer may, upon request, choose to integrate Flock Services with a third party to either distribute Integration Data or Customer Data (such third party, "Recipient"). Upon such request, Customer hereby grants to Flock a non-exclusive, non -transferable, royalty -free, perpetual license to access, share, view, record, duplicate, store, save, reproduce, modify, display, and distribute Customer Data and/or Integration Data, as required by the requested distribution, unless such accessing, sharing, viewing, recording, duplicating, storing, saving, reproducing, modifying, displaying, and distributing Customer Data and/or Integrated Data, including Customer's LPR data, as required by the requested distribution violates federal, state, and/or local laws applicable to Customer, including 625 ILCS 5/2-130. Customer acknowledges that such data may be viewed, recorded, duplicated, stored, saved, reproduced, modified, displayed, distributed, and retained by Recipient for a period longer than Flock's standard retention period and hereby provides consent to such retention period. Unless expressly listed in the Order Form, the provision, access, or rise of any Application Programming Interfaces ("APIs") is not included under this Agreement. Any rights, licenses, or obligations related to APIs shall be governed solely by the terms set forth in the Order Form or a separate agreement between the parties. Section 9.3 of the Agreement is amended to read as follows: 9.3 Flock indemnity. Flock shall indemnify and hold harmless Customer, its agents and employees, from liability of any kind, including claims, costs (including defense) and expenses, on account of: (i) any copyrighted material, patented or unpatented invention, articles, device or appliance manufactured or used in the performance of this Agreement; (ii) any damage or injury to property or person directly caused by Flock's installation of Flock Hardware, except for where such damage or injury was caused solely by the negligence of the Customer or its agents, officers or employees; or (iii) the dissemination or distribution by Flock of Customer Data, including Customer's LPR data, that results in a violation of Illinois law, including but not limited to, 625 ILCS 5/2-130(b)(1) and/or (b)(2). Flock's performance of this indemnity obligation shall not exceed the fees paid and/or payable for the services rendered under this Agreement in the preceding twelve (12) months. Section 11.1 of the Agreement is amended to read as follows: 11.1 Compliance with Laws. Parties shall comply with all applicable local, state and federal laws, regulations, policies and ordinances and their associated record retention schedules, including responding to any subpoena request(s) or laws governing the disclosure and dissemination of Customer Data, including 625 ILCS 5/2-130(b)(1) and (b)(2). Any applicable Flock Hardware/Software, Professional Services and/or One Time Purchases listed on the tablets) below are removed from the Agreement in its entirety. Billing Schedule Year 1 At Last Device installed $32,500.00 Annual Recurring after Year 1 $32,500.00 Contract Total $65,000.00 *Tax not included 11 pq a uM. n u" du ,111 An integrated public safety platform that detects, centralizes and decodes actionable evidence to increase safety, improve efficiency, and connect the Flock Safety Platform - Essentials community. Law enforcement grade infrashmcture-free (solar power + LTE) license plate recognition camera with Vehicle Fingerprint TM technology (proprietary Flock Safety LPR, tka Falcon machine learning software) and real-time alerts for unlimited users. Professional Services - Standard One-time Professional Services engagement. Includes site and safety assessment, camera setup and testing, and shipping and handling in accordance Implementation Fee with the Flock Safety Standard Implementation Service Brief. Professional Services - Advanced One-time Professional Services engagement. Includes site & safety assessment, camera setup & testing, and shipping & handling in Implementation Fee accordance with the Flock Safety Advanced Implementation Service Brief. FlockOS Features & Description The ability to request direct access to feeds from privately owned Flock Safety LPR cameras located in Community Network Access neighborhoods, schools, and businesses in your community, significantly increasing actionable evidence that clears cases. Unlimited Users Unlimited users for F1ockOS State Network (License Plate Lookup Only) Allows agencies to look up license plates on all cameras opted into the Flock Safety network within your state. With the vast Flock Safety sharing network, law enforcement agencies no longer have to rely on just their Nationwide Network (License Plate Lookup Only) devices alone. Agencies can leverage a nationwide system boasting 10 billion additional plate reads per month to amplify the potential to collect vital evidence in otherwise dead-end investigations. Law Enforcement Network Access The ability to request direct access to evidence detection devices from Law Enforcement agencies outside of your jurisdiction. Time & Location Based Search Search full, partial, and temporary plates by time at particular device locations License Plate Lookup Look up specific license plate location history captured on Flock devices Vehicle Fingerprint Search Search footage using Vehicle FingetprintTM technology. Access vehicle type, make, color, license plate state, missing / covered plates, and other unique features like bumper stickers, decals, and roof racks. Insights & Analytics Reporting tool to help administrators manage their LPR program with device performance data, user and network audits, plate read reports, hot list alert reports, event logs, and outcome reports. Receive automated alerts when vehicles entered into established databases for missing and wanted persons Real -Time NCIC Alerts on Flock ALPR Cameras are detected, including the FBI's National Crime Information Center (NCIC) and National Center for Missing & Exploited Children (NCMEC) databases. Unlimited Custom Hot Lists Ability to add a suspect's license plate to a custom list and get alerted when it passes by a Flock camera By executing this Order Form, Customer represents and warrants that it has read and agrees to all of the terms and conditions contained in the Master Services Agreement attached. The Parties have executed this Agreement as of the dates set forth below. FLOCK GROUP, INC. Customer: IL - Mount Prospect PD By: By: Name: Name: Title: Title: Date: Date: PO Number: